Background: Low income countries continue to experience high under-five mortality and a
high prevalence of protein energy malnutrition (PEM) among surviving children. There is lack
of empirical data for accurate tracking of child survival and for determining the consequences
of early childhood PEM on future health and education.
Main aim: To assess under –five mortality trends and associated factors to inform the design
of child survival interventions, and also examine the impact of childhood PEM on future
adolescent health and schooling among survivors in a rural population in Uganda.
Methods: Four studies were nested in the Kyamulibwa Health and Demographic Surveillance
Site in southwestern Uganda. In study 1, prospective data collected between 2002 and 2012
were extracted for 10,118 children under the age of five years and used to estimate age-specific
mortality rates using the synthetic cohort life-table method. Calendar year-specific hazard rates
and risk factors were explored by Cox regression. In study II, women of reproductive age
were enrolled and stillbirth rates were compared using i) 12 months recall of pregnancy
outcome (n= 1800) (method 1) and ii) lifetime recall (method 2) and associated risk factors
were explored. In study III, 1054 children followed to adolescence were categorised as
stunted/wasted, recovered, deteriorated and normal after three nutritional assessments
between 1999 and 2011. Mean blood pressures and schooling years achieved measured in 2011
were compared in the 4 groups. In study IV, a pragmatic trial, involving registration of
pregnancies and delivering stage-of-pregnancy-specific text message (SMS) via community
health workers to pregnant women in 13 intervention villages (n=262) compared with pregnant
women in control villages (n=263) with no intervention. Place of birth (home or health facility)
was the main outcome.
Results: Under-five mortality was 92 per 1000 live births. Overall mortality declined by 33%
between 2002 and 2012 with the highest decline observed in the post-neonatal period. Early
neonatal mortality did not change. Stillbirth rates differed by method of estimation; 26.2/1000
births versus 13.8/1000 births respectively by methods 1 and 2. No decline in stillbirth rates
was observed. Under-five mortality increased with decreasing child age, HIV infection of the
child, a birth interval 4 and a home
delivery. Stillbirth risk increased with maternal age and reduced with increasing parity. In
study III, wasting was negatively associated with systolic blood pressure (-7.90 95%CI [-
14.52,-1.28], p= 0.02) and diastolic blood pressure (-3.92, 95%CI [-7.42, -0.38], p= 0.03)
among surviving children. Recovery from wasting was positively associated with diastolic
blood pressure (1.93, 95%CI (0.11, 3.74] p=0.04). Both stunting and wasting regardless of
recovery were negatively associated with school achievement. In study IV, the SMS
intervention was associated with lower odds of homebirths [AOR=0.38, 95%CI (0.15-0.97)].
Home births were associated with muslim religion [AOR= 4.0, 95%CI (1.72-9.34)], primary or
no maternal education [AOR= 2.51, 95%CI (1.00-6.35)] and health facility distance ≥ 2 km
[AOR= 2.26, 95%CI (0.95-5.40)].
Conclusions: Survival of children in rural Uganda is improving, and could improve further
with increased uptake of family planning and facility births. Promoting community health
workers‘ role in improving child survival through use of mobile phones for delivering tailored
messages to mothers is a potential strategy that could be scaled up in rural communities